Welcome to the Orthodontist

Welcome to Suliman Orthodontics
We would like to welcome you and your child to our office. Our goal is to make every child's visit pleasant and educational. We strive to teach good oral care that will enable your child to have a beautiful smile that lasts a lifetime.
1. Tell Us About Your Child
Today's Date
Male Female
Child's Name *

Last First MI
Nickname
CHILD PREFERS TO BE CALLED
SS#
Child's Birthdate

Month Day Year
Child's Age
School:
Grade
Child's Home #

Area Code Phone Number
Hobbies/Sports:
Home Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
2. Who is Accompanying Your Child Today?
His/Her Name

First Name Last Name
Relation
Do you have legal custody of this child?

Yes No
Whom may we Thank for referring you?
List brothers/sisters with age:
General Dentist:
Last Visit Date:
Parent's Marital Status:

Single Married Widowed Divorced Separated Partnered
3. Parent's Information
Parent:

Mother Father Step Parent Guardian
Name

First Name Last Name
Birthdate
E-mail *
example@example.com
Cell #

Area Code Phone Number
Home Phone #

Area Code Phone Number
Employer
Work Phone #

Area Code Phone Number
Social Security #
Drivers License
Parent:

Mother Father Step Parent Guardian
Name

First Name Last Name
Birthdate
E-mail *
example@example.com
Cell #

Area Code Phone Number
Home Phone #

Area Code Phone Number
Employer
Work Phone #

Area Code Phone Number
Social Security #
Drivers License
4. Person Responsible For Account
Name

First Name Last Name
Relation
Billing Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Previous Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home #

Area Code Phone Number
Driver's Licence
Employer:
Work #

Area Code Phone Number
Ext:
Social Security #:
Who is responsible for making appointments?
Name

First Name Last Name
Home #

Area Code Phone Number
Work #

Area Code Phone Number
Ext:
5. Orthodontic Insurance
Primary
Orthodontic Coverage

Yes No
Dental Coverage

Yes No
Insurance Company Name
Insurance Company Phone #

Area Code Phone Number
Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Group # (Plan, Local or Policy #)
Policy Owner's Name
Relationship to Patient
Policy Owner's Birthdate

Month Day Year
Date
Socials Security #
Policy Owner's Employer:
Secondary
Orthodontic Coverage

Yes No
Dental Coverage

Yes No
Insurance Company Name
Insurance Company Phone #

Area Code Phone Number
Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Group # (Plan, Local or Policy #)
Policy Owner's Name
Relationship to Patient
Policy's Owner's Birthdate

Month Day Year
Date
Social Security #
Policy's Owner's Employer
6. Orthodontic History
What are the main concerns you would like orthodontics to accomplish?
Has your child ever been evaluated or had orthodontic treatment before?

Yes No
Have there been any injuries to the face, mouth, teeth or chin? *

Yes No
List any musical instruments played:
Have adenoids or tonsils been removed? *

Yes No
Has your child been informed of any missing or extra permanent teeth?

Yes No
Has your child ever had pain/tenderness in his/her jaw joint? (TMJ, TMD)? *

Yes No
Does your child brush his/her teeth daily? *

Yes No
Does your child floss his/her teeth daily?

Yes No
Child's Physician
Phone Number

Area Code Phone Number
Date of Last Visit

Month Day Year
Date
Is your child currently under the care of a physician?

Yes No
Has puberty begun?

Yes No
Has menstruation begun? (girls)

Yes No
Have you ever taken Fosamax, or any other bisphosponate? *

Yes No
If yes, when?
Please describe your physical health

Good Fair Poor
Please list all the drugs that your child is currently taking:
Please list any other drugs/things that your child is allergic to:
7. Has your child ever had any of the following medical problems?
Abnormal Bleeding *

Yes No
ADD/ADHD *

Yes No
Allergies to any Drugs *

Yes No
Allergies to Latex/Metals *

Yes No
Allergies to Plastic *

Yes No
Any Hospital Stays *

Yes No
Any Operations *

Yes No
Artificial Bones/Joints/Valves *

Yes No
Asperger Syndrome *

Yes No
Asthma *

Yes No
Autism *

Yes No
Cancer *

Yes No
Congenital Heart Defect *

Yes No
Convulsions/Epilepsy *

Yes No
Diabetes *

Yes No
Handicaps/Disabilities *

Yes No
Hearing Impairment *

Yes No
Heart Murmur *

Yes No
Hemophilia *

Yes No
Hepatitis *

Yes No
HIV +/AIDS *

Yes No
Kidney Problems *

Yes No
Liver Problems *

Yes No
Lupus *

Yes No
Rheumatic/Scarlet Fever *

Yes No
Sickle Cell Disease/Traits *

Yes No
Tuberculosis (TB) *

Yes No
Please discuss any medical problems that your child has ever had.
8. Does/Did your child have any of the following habits?
Clenching/Grinding Teeth

Yes No
Lip Sucking/Biting

Yes No
Mouth Breather

Yes No
Nail Biting

Yes No
Nursing Bottle

Yes No
Speech Problems

Yes No
Thumb/Finger Sucking

Yes No
Tongue Thrust

Yes No
A neighbor or relative not living with you.
Name

First Name Last Name
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Agree to Terms

I understand that the information I have given today is correct to the best of my knowledge. It will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status. I authorize the dental staff to perform the necessary dental services my child may need. If this office accepts insurance, I assign directly to Dr Suliman. all insurance benefits otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.
My method of payment will be:
Signature of Parent or Guardian

Clear
Date
Thank you for filling out this form completely.
This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.
Signature

Clear
Date
Initials
Should be Empty:

Welcome to Suliman Orthodontics

1. Tell Us About Your Child

2. Who is Accompanying Your Child Today?

3. Parent's Information

4. Person Responsible For Account

5. Orthodontic Insurance

6. Orthodontic History

7. Has your child ever had any of the following medical problems?

8. Does/Did your child have any of the following habits?